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Spinal C ord Injury Herniated Disc Spinal Cord Tumors. Pathophysiology Normal Spinal Cord. Spinal cord begins at the foramen magnum in the cranium Cord ends at the L1-L2 vertebra level Spinal nerves continue to the last sacral vertebra The Human Spine. Spinal Cord.

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Spinal C ord Injury Herniated Disc Spinal Cord Tumors

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    1. Spinal Cord InjuryHerniated DiscSpinal Cord Tumors

    2. PathophysiologyNormal Spinal Cord • Spinal cord begins at the foramen magnum in the cranium • Cord ends at the L1-L2 vertebra level • Spinal nerves continue to the last sacral vertebra • The Human Spine

    3. Spinal Cord Gray matter- cell bodies of voluntary and autonomic motor neurons White matter axons of ascending and descending motor fibers

    4. Normal Spinal Cord • White tracts send messages to and from the brain • Ascending Tracts- • carry into higher levels of CNS • touch, deep pressure,vibration, position, temperature • Descending Tracts • impulses for voluntary muscle movement

    5. Pyramidal- Voluntary movements Posterior column (Dorsal)- touch, proprioception, and vibration sense Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord) • voluntary movement

    6. Upper Motor Neurons UMN Originate in cerebral cortex Project downward Result in skeletal muscle movement Injury = SPASTIC paralysis Lower Motor Neurons LMN Originate at each vertebral level Project to specific parts of the body Result in movement /sensation Injury = FLACCID paralysis

    7. Normal Spinal Cord Reflex Arc • Involuntary response to a stimulus • Where sensory and motor nerves arise from cord • Sensory fibers enter posterior • Synapse in the grey matter • Motor fibers leave anterior • Once outside cord join form spinal nerve • reflex movement

    8. Normal Spinal Cord Dermatones • Skin innervated by sensory spinal nerves • Myotome- muscle group innervated by motor neurons

    9. Nervous System and the Spinal Cord • ANS can be affected by SCI • Sympathetic chains on both sides of the spinal column (T1-L2) • Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

    10. Spinal Cord Protection Bones- vertebral column 7 Cervical 12 Thoracic 5- Lumbar 5- Sacral Discs- between vertebra

    11. Spinal Cord Protection • Internal and external ligaments • Dura • Meninges • CSF in subarachnoid space allow for movement within spinal canal

    12. Etiology of Traumatic SCI • MVA- most common cause • Other: falls, violence, sport injuries • SCI typically occurs from indirect injury from vertebral bones compressing cord • SCI frequently occur with head injuries • Cord injury may be caused by direct trauma from knives, bullets, etc

    13. Etiology of Traumatic SCI • 78% people with SCI are male • Typically young men – 16-30 • Number of older adults rising (>61 yr) • Greater complications • Life Expectancy 5 years less than same age without injury • 90% go home

    14. Spinal Cord Injury- SCI • Compression • Interruption of blood supply • Traction • Penetrating Trauma

    15. Spinal Cord Injury • Primary • Initial mechanism of injury • Secondary • Ongoing progressive damage • Ischemia • Hypoxia • Microhemorrhage • Edema

    16. Spinal Cord Injury • Hemorrhage and edema occur in the cord post injury, causing more damage to cord • Extension of the cord injury from cord edema can occur over the first few days • watch the phrenic nerve! • Initially SCI experience spinal shock • depression of all cord & ANS function below injury. Lasts from few min to wks

    17. Spinal and Neurogenic Shock • Spinal Shock • Decreased reflexes and loss of sensation below the level of injury • Motor loss- flaccid paralysis below level injury • Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury • Lasts days to months

    18. Spinal and Neurogenic Shock Neurogenic shock • Due to loss of vasomotor tone • SNS loss results in parasympathetic dominance with vasomotor failure • Loss of SNS innervation causes peripheral pooling and decreased cardiac output • Hypotension and Bradycardia • Orthostatic hypotension and poor temperature control (poikilothermic)

    19. How do you know spinal shock is over? • Clonus is one of the first signs • Hyperreflexia of foot • Test by flexing leg at knee & quickly dorsiflex the foot • Rhythmic oscillations of foot against hand • clonus

    20. Classifications of SCI • Mechanism of Injury • Skeletal and Neurologic Level • Completeness (degree) of Injury Mechanism of Injury Flexion Hyperextension Compression Flexion /Rotation

    21. Classifications of SCIMechanism of Injury Flexion (hyperflexion) • Most common because of natural protection position. • Generally cause neck to be unstable because stretching of ligaments

    22. Classifications of SCIMechanism of Injury Hyperextention • Caused by chin hitting a surface area, such as dashboard or bathtub • Usually causes central cord syndrome symptoms

    23. Classifications of SCIMechanism of Injury Compression • Caused by force from above, as hit on head • Or from below as landing on butt • Usually affects the lumbar region

    24. Classifications of SCIMechanism of Injury Flexion/Roatation • Most unstable • Results in tearing of ligamentous structures that normally stabilize the spine • Usually results in serious neurologic deficits

    25. Skeletal level • Vertebral level where the most damage to the bones • Neurologic level • The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body • Levels of Function in Spinal Cord Injury

    26. Classification of SCI- Level of Injury Spinal cord level • When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level. • the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

    27. Classifications of SCICompleteness (Degree) of Injury • Complete • Incomplete • Central cord syndrome • Anterior Cord syndrome • Brown-Sequard Syndrome • Posterior Cord Syndrome • Cauda Equina and Conus Medullaris

    28. Classification of SCI Completeness (degree) of Injury Complete (transection) • After spinal shock: • Motor deficits- • spastic paralysis below level of injury • Sensory- • loss of all sensation perception • Autonomic deficits- vasomotor failure and spastic bladder

    29. Classification of SCI Completeness (degree) of Injury Incomplete Central Cord Syndrome • Injury to the center of the cord by edema and hemorrhage • Motor weakness and sensory loss in all extremities • Upper extremities affected more

    30. Classification of SCI Completeness (degree) of Injury Incomplete Brown-Séquard Syndrome • Hemisection of cord • Ipsilateral paralysis • Ipsilateral superficial sensation, vibration and proprioception loss • Contralateral loss of pain and temperature perception

    31. Classification of SCI Completeness (degree) of Injury incomplete • Anterior Cord Syndrome • Injury to anterior cord • Loss of voluntary motor, pain and temperature perception below injury • Retains posterior column function (sensations of touch, position, vibration, motion)

    32. Classification of SCI Completeness (degree) of Injury incomplete • Posterior Cord Syndrome • Least frequent syndrome • Injury to the posterior (dorsal) columns • Loss of proprioception • Pain, temperature, sensation and motor function below the level of the lesion remain intact

    33. Classification of SCI Completeness (degree) of Injury incomplete • ConusMedullaris • Injury to the sacral cord (conus) and lumbar nerve roots • CaudaEquina • Injury to the lumbosacral nerve roots • Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

    34. Clinical Manifestations of SCI • Skin: • pressure ulcers • Neuro: • pain • sensory loss • upper/lower motor deficits • autonomic dysreflexia • Cardio: • dysrhythmias • spinal shock • loss of SNS control over blood vessels • orthostatic hypotension, • poikilothermic

    35. Respiratory- • decrease chest expansion, cough reflex & vital capacity • diaphragm function-phrenic nerve • GI • stress ulcers • paralytic ileus • bowel- impaction & incontinence • GU • upper/lower motor bladder • Impotence • sexual dysfunction • Musculoskeletal • joint contractures • bone demineralization • osteoporosis • muscle spasms • muscle atrophy • pathologic fractures • para/tetraplegia

    36. Common Manifestation/Complications Upper and Lower Motor Deficits • Upper motor deficits result in spastic paralysis • Lower motor deficits result in flaccid paralysis and muscle atrophy

    37. Common Manifestations/Complications • Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level • Such as C6; L4 spinal cord injury • Terms used to describe motor deficits • Prefix: • para- meaning two extremities • tetra- or quadra- all four extremities • Suffix : • -paresis meaning weakness • -plegia meaning paralysis Quadraparesis means what?

    38. Common Manifestations/Complications • C1-3 usually fatal- • Loss of phrenic innervation ventilator dependent • No B/B control • Spastic paralysis • Electric w/c with chin/mouth control

    39. Common Manifestations/Complications • C6- weak grasp • Has shoulder/biceps to transfer & push w/c • No bowel/bladder control. • Considered level of independence

    40. Common Manifestations/Complications • T1-6- full use of upper extremity • Transfer • Drive car with hand controls and do ADL’s • No bowel/bladder control

    41. Immediate Care Emergency Care at Scene, ER & ICU • Transport with cervical collar • Assess ABC’s; O2; tracheotomy/vent • IV for life line • NG to suction • Foley

    42. Diagnostic Studies for SCI • X-ray of spinal column • CT/MRI • Blood gases

    43. Therapeutic Interventions • Medications • IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema

    44. Therapeutic Interventions • Medications • To control or to prevent complications of SCI and immobility: • Vasopressors to maintain perfusion • Histamine H2 blockers to prevent stress ulcers • Anticoagulants • Stool softeners • Antispasmodics

    45. Therapeutic Interventions Stabilization/ Immobilization Traction- Gardner-wells tongs Halo Casts Splints Collars Braces

    46. Therapeutic Interventions Surgery for SCI • Manipulation to correct dislocation or to unlock vertebrae • Decompression laminectomy • Spinal fusion • Wiring or rods to hold vertebrae together

    47. Nursing Management Assessment • HEALTH HISTOY • Description of how and when injury occurred • Other illnesses or disease processes • Ability to move, breathe, and associated injury such as a head injury, fractures

    48. Nursing Management Assessment PHYSICAL EXAM • LOC and pupils- may have indirect SCI from head injury • Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds • Vital signs • Motor • Sensory • Bowel and bladder function